New Patient Form

New Patient Form

If for some reason you cannot complete this form, please try to show up a few minutes early to your appointment, and we will provide you with a form when you get here. Thanks for your cooperation and we look forward to your visit!!

New Patient Form

- Step 1 of 5

Patient's Name *

Age *

Birthdate *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Gender *

Male

Female

Have you had previous orthodontic consultations? *

Yes

No

Previous orthodontic treatment? *

Yes

No

If so, when/where?

Doctor's Name

What is the primary reason you are seeking this orthodontic evaluation? *

Who may we thank for referring you to Feldman Orthodontics?

RESPONSIBLE PARTY INFORMATION

(If patient is under 18)

Name

Relation to Patient

Marital Status

S

M

W

D

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

Birthdate

Employer

# Yrs. Employed?

Occupation

Work Phone

Spouse's Name (if applicable)

Spouse's Phone

Spouse's Employer

Spouse's Occupation

DENTAL INFORMATION

Patient's Dentist *

Patient's Last Dental Visit *

Has patient had facial or dental injury due to accidents? *

Has the patient ever experienced pain, clicking, or popping in his/her jaw joints?

Yes

No

Pain

Right

Left

Clicking

Right

Left

Popping

Right

Left

Earaches

Right

Left

MEDICAL INFORMATION

Patient's Overall Health *

Excellent

Good

Poor

Is patient currently under the care of a doctor, other than for routine examinations? *

Yes

No

If yes, for what?

Is patient currently taking any medication? *

Yes

No

If yes, for what?

Does the patient currently have, or has the patient ever had any of the following? (if yes, check box)